Information Collection

Pretest for the Medical Office VE survey

IC 206676 under ICR 201304-0935-003 · OMB 0935-0211.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #4 Pretest for the Medical Office VE survey	Form and Instruction
Form #4 Pretest Survey for Medical Office VE Survey Attachment D - Pretest Survey for Medical Office VE Survey_1-17-13.docx	Form and Instruction
Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey.docx Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #4	Pretest Survey for Medical Office VE Survey	Attachment D - Pretest Survey for Medical Office VE Survey_1-17-13.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 504

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	504	504
Annual IC Time Burden (Hours)	126	126
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey	Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey.docx	04/18/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.